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          <h1 class="post-title" itemprop="name headline">《牙体预备标准化操作》读书笔记04</h1>
        

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        <p>第四章 预备前分析设计<br>谋定而后动。<br>牙体预备的两种情况：①形态和排列都很理想，单纯颜色问题。可直接在原牙上做背板进行备牙。属于相对简单的。不是每一颗无髓牙都需要冠修复，正确的内漂白后采用必要的瓷贴面等微创修复形式是首选。除非前牙腭侧或后牙近远中边缘嵴均受损严重，才需要考虑全冠修复。即使是全冠，也推荐更加微创的贴面冠。（这个问题，刚出了本书，根管治疗后修复方案的。）②涉及到形态和排列的问题，相对复杂。严重排列不齐，正畸。轻度牙齿排列不齐，可以考虑瓷贴面解决。正畸后修复或轻度不齐直接修复，需认真考虑是否可以更加微创地解决，严重不建议多颗全冠解决牙齿排列不齐的方案。只有个别一两颗有明显排列不整齐的、且患者数次坚决拒绝正畸后，方可考虑采用冠修复，但也要非常谨慎。<br>在间接修复李，瓷贴面应该是首选——实在不行了，才做瓷冠。<br>只要涉及形态和排列问题，就需要进行全面细致的美学分析。<br>若情况简单，可用树脂直接在口内mock-up，确认后，取硅胶背板，预备。<br>若涉及多颗牙，情况复杂，制作蜡型wax-up，然后mock-up，不能简单要求技师进行蜡型设计，要有明确指导。<br>用DSD/PSD来进行电脑模拟。DSD/PSD的结果也要用蜡型和mock-up来检验。<br>如果不认真操作一个流程，还不如不做。<br>精准的蜡型设计应该达到如下标准：①精准的咬合关系模拟：常规使用面弓转移患者上颌牙列与铰链轴的关系，用股橡胶或聚醚给技师最准确的上下颌印模和牙合记录硅胶制取的正确牙合记录，不建议使用藻酸盐取模，即使是分析模型和对颌模型。②符合美学理论：多颗牙美学修复时，美学、咬合、发音等各方面的检查都应通过。医生应根据DSD/PSD测量出来的数据，为技师的蜡型制作提供精准的数据。③精准的排列关系。④精准的牙齿形态设计。⑤满足修复工艺需求。⑥通过mock-up检验。<br>进行mock-up<br>现在口外检查外形，咬合，美观。请患者参与。然后用硅胶背板和临时冠材料将蜡型翻制到患者口内检查。硅胶背板要从龈缘位置切去，方便临时冠材料排溢。<br>背板在就位时，手指切不可加力。材料凝固初期，将探针钩入硅胶背板唇侧，轻轻外拉，取下硅胶背板。<br>对于局部凸出的牙体，可将牙齿凸出部位排在蜡型的唇侧，将局部硅胶切除即可制作mock-up。<br>mock-up制作完成后，医生要迅速进行美学、咬合、发音检验，不能有明显问题。用100μm，40μm，8μm咬合纸检查正中非正中咬合；测试M、S、E、F等发音。简单病例，可以直接备牙。复杂病例，先让患者戴用一段时间mock-up。一般2-4周，要认真调合，做到正中、非正中调合正确。<br>如医患双方无法都满意效果，则应终止诊疗。<br>没有足够把握、没有认真的分析设计，不要在患者牙齿上进行任何不可逆操作。<br>微调mock-up：①不能轻易调改，要基于美学分析理论，而不是患者的要去。②要有对牙齿形态的敏感。③要在正确的体位下观察并调整：12点位调整，6点位观察。④调整要少，循序渐进，可以分次进行，不能大刀阔斧。⑤就多不就少。<br>硅橡胶背板：要制作两份。一份作为预备过程中的检验工具，医生需要分段切开以精准检验牙体预备量。要比预备牙齿左右各多取两颗，以利于硅胶背板的稳定就位。厚度不能小于5mm，尤其唇侧和切缘。颈部也要超过牙齿颈缘5mm。<br>其重要意义就是用正确的设计形态来检验牙齿预备后形态是否合格，预备量不能多，不能少。<br>另一份硅胶背板的作用：①精准制作临时修复体，不能用力，避免硅胶背板变形。②将完整的硅胶背板交给技师，作为技师制作最终修复体的模板。<br>制作要点：<br>①按说明书来，操作期不能过慢，聚合期不能加压，稳定期时间不能缩短，室温不能太高。可使用软质的缩聚硅橡胶。节省成本。<br>②左右各延展两颗牙齿的范围。<br>③厚度超过5mm，尤其避免由于唇侧和切缘过薄造成的硅胶指示错误。<br>④唇腭侧颈缘需超出颈缘5mm。<br>⑤加成型硅胶需要使用丁腈(ding jing)手套，同时冷水洗手降低手的温度。看颜色判断是否调和均匀。<br>⑥聚合期，千万不要加牙或移动位置，否则会造成印模变形。<br>⑦注意硅胶需紧贴牙齿，可快速将少量硅胶涂抹在预备牙齿的唇腭侧，需注意避免与后来置入的硅胶分层。<br>将背板沿要预备的牙体正中央切割后，保存好，作为预备中的检查工具。<br>纵切法：唇腭侧颈部正中，切缘正中各画一点，用刀片从颈部向切端切割，用主力眼观察，确保切割平面正确。<br>任何牙齿预备前，都必须有至少两个正确的硅胶背板，否则不能预备。<br>牙体预备之前，一定要遵循先加后减的原则。<br>硅胶背板翻制的应该是正确的牙齿设计形态，通过各种设计手段获得正确的形态设计，不能没设计先备牙。<br>牙体预备两件事情最重要：①精准预备出设计形态：不难；②确保设计形态的正确：很难，需要认真学习。<br><strong>(总结：牙体预备前的设计分析阶段。主要是DSD/PSD分析，蜡型wax-up，直接或间接mock-up，制作硅胶背板等步骤。这些其实比备牙要重要得多。关于PSD，需要使用的是Photoshop，但是这是商业软件，很贵的。用盗版当然可以，但是由于在单位使用，又是用来盈利的，可能会有法律风险。我试了一下开源免费的gimp，貌似也是可以用的。尝试了一下把我以前的一个病例的牙齿修改形状，与对侧同名牙一致。</strong><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0143--ytbzhyb4/01.png"><br><strong>这是用的PS里的液化的方法，gimp里叫扭曲变换。<br>再试一下用其它方法，把同名牙复制过来，水平翻转。</strong><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0143--ytbzhyb4/02.png"><br><strong>还行。）</strong><br>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“好看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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